Adherence to the WHO movement behaviour guidelines and associations with health and development among young children in Ethiopia

Background: In 2019, the World Health Organization (WHO) introduced guidelines on physical activity, sedentary behaviour, and sleep for children under five years of age. Most studies informing these guidelines originated from high-income countries, raising concerns as 90% of children in this age group live in low- and middle-income countries (LMICs). Few studies have been published on these behaviours among preschool-aged children in Africa and none from Ethiopia. This thesis aimed to bridge this gap with three primary objectives: first, it assessed the feasibility and acceptability of studying adherence to the WHO guidelines in Ethiopia and explored the associations between guideline compliance and health and development among children; second, it examined locally appropriate strategies and disseminated the study findings; and third, it reviewed existing literature on movement behaviours among forcibly displaced children in conflict or disaster settings.

Methods: The thesis comprised six studies. The first study assessed the feasibility and acceptability of the study protocol. The second study examined adherence to the WHO movement behaviour guidelines and their associations with socio-demographic factors. The third study investigated the relationship between guideline compliance and health and development outcomes. The fourth study focused on the correlates of meeting the WHO guidelines. The fifth study explored locally tailored strategies for disseminating research findings. The sixth study was a scoping review on movement behaviours and health outcomes among forcibly displaced children in conflict or disaster settings. The first four studies of the thesis employed a cross-sectional study design involving Ethiopian children (3-5 years), recruited from kindergartens in Adama city and rural villages in the Lume District. Physical activity and sleep were measured using ActiGraph accelerometers, while screen time was parent-reported. Additional measurements included height and weight (BMI z-score), and assessments of motor skills (NIH Toolbox) and executive functions (Early years Toolbox). Study 5 translated the findings from Studies 2 and 3 using a Community-Engaged Research Dissemination Framework. The scoping review was conducted using the Joanna Briggs Institute methods for scoping reviews and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extensions for Scoping Reviews.

Results: The initial study confirmed the feasibility and acceptability of the study protocol in Ethiopian context, with an 89% compliance rate for accelerometer wear and complete data for all measurements. In the second study, 58% of children met all the WHO guidelines, with a higher proportion meeting the physical activity (96%) and sleep (92%) guidelines compared to the screen time guideline (64%). A higher proportion of rural children met the guidelines for screen time, sleep and all the three combined compared to their urban counterparts (85% vs 38%, 99% vs 84% and 81% vs 30%, respectively) with minimal differences between boys and girls. The third study found that longer sleep duration correlated with lower adiposity, while both total physical activity (TPA) and moderate- to vigorous-intensity physical activity (MVPA) were associated with better muscular strength. Outdoor play was positively associated with higher TPA and MVPA, longer sleep, and reduced screen time. Children of educated parents had lower TPA and MVPA and higher sedentary time compared to those with uneducated parents. Children using screens for educational purposes had less MVPA, shorter sleep, and more screen time. Girls participated in less physical activity (both TPA and MVPA) and more sedentary behaviour than boys. The fifth study highlighted the importance of translating research through culturally and contextually informed strategies in Ethiopian settings. The strategies identified included sharing tailored individual results with parents, sharing summary findings with educators and local stakeholders, conducting a dissemination workshop and holding a media briefing. Finally, the scoping review identified significant evidence gaps in movement behaviours among forcibly displaced children, who had low levels of physical activity and high sedentary behaviour, which was associated with adverse health outcomes such as increased obesity risk, weaker muscular strength, and increased developmental delays.

Conclusion: This thesis proved the feasibility of conducting research on 24-hour movement behaviours and health outcomes among young children in Ethiopia. It found that rural children had higher compliance with WHO guidelines than urban children, indicating a need for targeted strategies in urban areas. Future research should involve larger, representative samples across more regions in Ethiopia. The effective dissemination strategies employed lay a strong foundation for future knowledge translation efforts in LMICs. In displacement contexts, immediate action is essential to improve movement behaviours and uphold the right to play for forcibly displaced children.